護理師監測正在接受輸血的病人，病人突然出現畏寒、發燒及下背痛。護理師的首要行動為何？
A nurse is monitoring a client receiving a blood transfusion. The client suddenly develops chills, fever, and low back pain. What is the priority nursing action?
- AStop the transfusion immediately✓ 正解立即停止輸血
- BNotify the laboratory通知檢驗科
- CSlow the transfusion rate減慢輸血速率
- DAdminister an antipyretic給予解熱劑
畏寒、發燒與下背痛是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的典型「三聯徵」。溶血反應是因輸注不相容血液，導致紅血球破裂，釋放出的血紅素會阻塞腎小管，導致急性腎衰竭。護理師一旦發現，首要原則是立即停止輸血，確保病人生命安全，並以生理食鹽水維持靜脈路徑通暢，隨後依照醫院程序處理。
Chills, fever, and low back pain constitute the classic triad of an acute hemolytic transfusion reaction. A hemolytic reaction occurs when incompatible blood is transfused, resulting in red cell lysis; the released hemoglobin obstructs the renal tubules and can precipitate acute renal failure. Once the nurse recognizes this reaction, the priority principle is to stop the transfusion immediately to ensure patient safety, maintain IV access patency with normal saline, and then manage the situation according to institutional protocol.